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For The Record
E-Newsletter    February 2023
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Editor's E-Note

Once HIM professionals were restricted to a handful of career choices. Now, the opportunities have mushroomed. Darice Grzybowski looks at some of the new roles waiting to be filled by HIM grads.

In addition to reading our e-newsletter, be sure to visit For The Record’s website at www.fortherecordmag.com. We welcome your feedback at edit@gvpub.com. Follow For The Record on Facebook and Twitter, too.

Kate Jackson, editor
In This E-Newsletter
E-News Exclusive

2023 HIM Career Path Update

By Darice Grzybowski, MA, RHIA, FAHIMA

What great opportunities exist for HIM professionals seeking a new career path! Traditionally a graduate of an HIM college program had a choice of entering a traditional health care environment role such as a coder, release of information tech, tumor registrar, transcriptionist, or manager (as well as a variety of other specialist roles). Alternatively, they could enter what was called a “nontraditional” role, which typically meant working in an alternate setting such as ambulatory care or longer term care, for a pharmaceutical company, or even for a software or other type of sales-oriented corporation.

Both of these choices still exist, of course, but the scope and sheer number of different types of jobs available in both those settings have not only dramatically expanded, but additional work setting possibilities have arisen in droves.

Some examples of newer jobs in the health care setting include compliance and privacy officers, COVID tracking and data specialists (side impact of the pandemic), EHR quality control and audit, remote staff supervision, inpatient and outpatient clinical documentation integrity specialists, IT clinical applications educator, and patient advocate.



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Ask the Expert
Have a coding or documentation question? Get an expert answer by sending an email to edit@gvpub.com.

This month’s selection:
Our professional coding department is having a discussion on how the ultrasound scrotum, with the additional duplex study, should be documented and coded.

We have set up a site provider approved template with the technique line reading as highlighted below but our providers weren’t specifically documenting arterial and venous flow in their findings: section of the reports, so we added the Doppler findings: section with the elements required to code for the duplex portion of exam.

Some of our coders were picking up varicocele as an element for the venous portion of a duplex charge and coding limited—93976; is that correct?

Would it also be correct to assume our templates state all of the elements in the technique line to code for the duplex portion?

Jennifer A. Fry, CPC
Coder II
Professional Coding Services

From what we can determine from the information given, the For the Record reader wants to know if they can code a duplex study without vasculature flow data. We would have to see the template to see if their template format would be sufficient to report a duplex study. Also, we may not have all of the details of the circumstances. However, the simple answer is no. If Doppler is performed, it is intended to be for the specific purpose of identifying stenotic disease. Included components would be color flow analysis of blood flow, velocity, and waveform analysis. If only a structure is identified but not the intended purpose of the test, then it shouldn't be reported. It would be more appropriately billed as an ultrasound. Dr. Zielske even touches on this topic by saying in the section reserved for visceral organ vascular studies, "Do not report code 93975 or 93976 when color Doppler is used for quick assessment of whether there is blood flow or when used just to identify a structure."

Coder response:
Here is a complete report with our set template technique line (that most of our providers do not pay attention to delete or add info) that states all of the requirements, but in the findings section of our radiologist’s dictated report, there is no mention of arterial flow or venous flow, just pulse-wave Doppler flow and mention of no varicocele or hydrocele noted.

Expert response:
I reviewed this diagnostic study, and this would be coded as a diagnostic ultrasound and not as a duplex study. The findings are very specific to testicular structures. The only notation of vasculature is from a structural standpoint and the Doppler flow imaging appears to be used to identify possible orchitis, not a vascular complaint. As Dr. Zielske stated, a Doppler element used to diagnose a structural defect would not be sufficient to support a duplex code. I would code this as 76870. Please reference my initial rationale to complement this rationale.

— John Piaskowski, CPC-I, CPMA, CIRCC, CCC, CCVTC, CGIC, CGSC, CUC, COSC, CRC, is a coding consultant for numerous organizations specializing in cardiology and urology. He has over 13 years of experience in coding, auditing, education, and documentation standards.
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